One Friday afternoon last March, my manager asked me to represent nursing on a team of infection preventionists and epidemiologists to discuss the possibility of initiating a warm zone model (WZM). Until this point, I had been closely involved in opening our acute care units if the hospital was cohorting COVID-19-positive and person under investigation (PUI) patients. My role had primarily been validating personal protective equipment (PPE) skills and real-time training.
The goal of this team was to create alternative ways to improve staff safety with a secondary outcome of PPE preservation. Processes were already in place to disinfect and reuse eye protection and N95 masks. Our focus was on extending the use of our PPE gowns and creating a WZM.
Our first order of business was to define our zones. The EPA highlights three separate zones when considering healthcare personnel at risk for contamination: hot, warm and cold. Hot zones contain the greatest risk for contamination; these areas include the COVID-19-positive patient rooms. Warm zones contain a moderate risk for contamination. This zone includes the area or space where our donned clinicians are bridging between rooms of COVID-19-positive patients through the designated warm zone. The cold zone refers to areas with no risk for contamination, such as the nurse’s station, supply rooms and medication rooms. Bridging is the movement of a donned clinician from one patient room to another through the designated warm zone.
One thing was clear: We needed to utilize a team approach to patient care. A donned clinician is directly caring for COVID-19-positive patients (hot zone). A resource individual (buddy) is a second staff member outside the patient room in the cold zone. The buddy’s main function is to provide the donned clinician with any additional medications or supplies.
The team assessed the feasibility of a WZM in regard to unit geography. On acute care units, the patient rooms are located on one side of the hallway. The team agreed to a warm zone breadth of 40 inches from the door and ran a strip of red duct tape the entire length of the hall. All equipment and supplies were moved out of this warm zone. Our critical care units supported a different architectural infrastructure than many other units. The family space surrounding the external periphery of the patient rooms became the warm zone, which allowed the central nurses’ station at the core of the unit to remain a cold zone. The only equipment present in the warm zone is gloves, hand sanitizer and trash cans.
The WZM works best when a unit is housing only COVID-19-positive patients. Our hospital was able to implement this model on three acute care units and five critical care units. For units with a mixture of known COVID-19-positive and PUI patients, safety measures were implemented to prevent warm zone bridging from a known COVID-19-positive patient’s room to a PUI patient’s room.
In early April, we began educating staff about the model and allowing staff to share their experiences and examples of time saved using the WZM. The team noticed improved knowledge of PPE donning and doffing procedures and reduced risk for self-contamination. Another helpful approach to support the WZM was to encourage clustering care and adopting total nursing care to minimize staff entering/exiting the hot zone more than needed. As COVID-19 admissions continue to rise, cohort unit staffing has increased, as well as utilization of the WZM across the Emory system. At Emory Healthcare, we developed useful resources from care protocols and guidelines to telemedicine and training. Look for our complete report in the January issue of American Journal of Nursing.
If your unit has adopted a WZM, what advantages and safety improvements have you experienced?